Insurance Request LDBA | Register OBA

2024 Insurance Certificate Request Form -LDBA

All information must be provided to expedite your request. Missing information will result in a delay. Please allow 2 business days to complete your request.

Local Association Contact Information

First Name

Last Name

Phone

Local Associatin

Affiliate DESIGNATE - Contact Info

Insurance Information

Do you require a Certificate of Insurance with a specific additional insured?

Ex) Municipality, school board, training facility

Please select

YES

If yes - Additional insured name and address is a MUST!. Please note, proper legal name and full address are required. Missing information will result in your request being denied.

Additional Info

I confirm I have entered the full insured name and address in the above text box. I further understand that my request will be denied if incomplete.